NCLEX NCLEX-RN Online Practice Questions and Exam Preparation

NCLEX NCLEX-RN Online Questions & Answers

• Question 181:

  The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

  A. Pedal pulses 11 (weak)
  B. Twenty-four-hour intake 1000 mL/day for past 2 days
  C. Serum potassium 3.3
  D. Pulse rate 150 bpm
  B. Twenty-four-hour intake 1000 mL/day for past 2 days

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  (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.

• Question 182:

  A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:

  A. "You shouldn't do things like that, just tell someone you feel bad."
  B. "Tell me more about what you couldn't take anymore."
  C. "I'm sure you probably didn't mean to kill yourself."
  D. "How long have you been in the hospital."
  B. "Tell me more about what you couldn't take anymore."

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  (A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.

• Question 183:

  A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

  A. Be comforted when he is held
  B. Cry
  C. Not notice that his mother has left
  D. Withdraw and become listless
  B. Cry

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  (A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.

• Question 184:

  A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

  A. The test is inconclusive and should be repeated
  B. Further testing is needed
  C. The test is normal and the fetus is reacting appropriately
  D. The fetus is distressed
  C. The test is normal and the fetus is reacting appropriately

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  (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.

• Question 185:

  A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

  A. Encourage exercises in the unaffected extremities.
  B. Encourage her to cross and uncross her legs.
  C. Check neurological and circulatory status of the affected leg hourly.
  D. Place a trochanter roll along the upper thigh of the affected leg.
  B. Encourage her to cross and uncross her legs.

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  (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.

• Question 186:

  A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:

  A. Fresh vegetables and fruit
  B. Canned vegetables and fruit
  C. Breads, cereals, and rice
  D. Fish
  B. Canned vegetables and fruit

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  (A) Fresh vegetables and fruits are excellent sources of essential vitamins. (B) Canned and frozen foods have a high sodium content. Labels of all canned foods should be read to determine if sodium is used in any form. (C) Bread, cereal, and rice are excellent sources of carbohydrates. (D) Fish is an excellent source of protein.

• Question 187:

  On the third postpartum day, the nurse would expect the lochia to be:

  A. Rubra
  B. Serosa
  C. Alba
  D. Scant
  A. Rubra

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  (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4?0. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.

• Question 188:

  A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:

  A. Respiratory obstruction
  B. Hypercalcemia
  C. Fistula formation
  D. Myxedema
  A. Respiratory obstruction

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  (A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.

• Question 189:

  A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?

  A. Abruptio placentae
  B. Ectopic pregnancy
  C. Massive uterine rupture
  D. Placenta previa
  A. Abruptio placentae

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  (A) Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. (B) Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. (C) Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. (D) Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.

• Question 190:

  A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?

  A. "I feel angry when I hear that tone of voice."
  B. "You make me angry when you talk to me that way."
  C. "Are you trying to get me angry?"
  D. "Why do you treat me that way?"
  A. "I feel angry when I hear that tone of voice."

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  The nurse appropriately states how he or she feels when the client speaks in a condescending manner. (B) This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice.

  (C) "Why" questions usually put a person on the defensive. In addition, the client cannot "make" the nurse angry. The client does not have that control. (D) Again, a "why" statement places the client on the defensive.